DISTR. : LIMITED

DISTR. : LIMITEE ~ .. ~ a WORLD HEALTH ORGANIZATION

\ . . ~ ORGANISATION MONDIALE DE LA SANTE WHO/VDT/89.446 ORIGINAL: ENGLISH

~

STD CONTROL IN PROSTITUTION

REVIEW OF THE PROBLEM - INTERVENTION STRATEGIES

WHO Consultation on Prevention and Control of Sexually Transmitted Diseases in Population Groups at Risk

Geneva, 24-27 October 1988

Programme for Sexually Transmitted Diseases

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Les opinions exprimees dans les documents par des auteurs cites nommement n'engagent que lesdits auteurs.

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1. INTRODUCTION

TABLE OF CONTENTS

2. SOCIOECONOMIC PERSPECTIVES OF PROSTITUTION

2.1. Reasons for entry into prostitution 2.2. Supply and demand 2.3. Client factors 2.4. Types of prostitution and places of work 2. 5. Mobility

3. EPIDEMIOLOGY OF STD IN PROSTITUTES

3.1. Clients 3.2. Prostitutes as source of infection 3.3. Prevalence of STD in prostitutes

4. BEHAVIOURAL ASPECTS

4.1. Knowledge of and attitudes towards various STD, preventive measures, and their use

4.2. Health seeking behaviour

5. PRIMARY PREVENTION

5.1. STD education 5.2. STD educational programmes for prostitutes 5.3. Evaluation 5.4. Methods of primary prevention

6. EARLY DETECTION OF STD

6.1. Reinfection rate 6.2. Cluster testing 6.3. Walk-in clinic 6.4. Outreach approach 6. 5. Management

7. SYSTEMIC CHEMOPROPHYLAXIS INCLUDING SELECTIVE MASS TREATMENT

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8. THE ROLE OF LEGISLATION

8.1. Control of prostitution 8.2. International intruments

9. RESEARCH PRIORITIES

9.1. Epidemiology and behavioural aspects 9.2. Diagnosis and treatment aspects 9.3. Prevention and control

10. RECOMMENDATIONS

10.1. Recommendations to Member States 10.2. Recommendations to WHO

11. SUMMARY AND CONCLUSIONS

TABLE 1. Prevalence of Sexually Transmitted Disease in Prostitutes

REFERENCES

LIST OF PARTICIPANTS

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l. INTRODUCTION

Prostitution has been historically associated with high levels of sexually transmitted diseases (STD). Prostitutes and their clients have attracted the attention of health authorities for a long time because of concern over their roles in the spread of STD (Brandt, 1987). This concern has become more urgent due to the advent and spread of human immunodeficiency virus (HIV) infection which is mainly transmitted through sexual intercourse and nearly always fatal. In some areas, the high prevalence is associated with intravenous drug use (Darrow et al., 1990). The prevalence of HIV infection among prostitutes currently ranges from zero in some areas to over 80% in others. Thus in some countries prostitution does not seem to be important in HIV transmission at the present time. However, in some parts of Africa, prostitutes and their clients are major transmitters of HIV (Van de Perre et al. 1985; Kreiss et al. 1986; Piot et al. 1987). Prostitutes and their clients are, therefore, important target groups for STD control.

There is increasing evidence that a number of sexually transmitted diseases act as risk-factors or facilitators of HIV transmission (Pepin et al., 1989). This necessitates renewed attempts at STD control. A significant decrease in the incidence of syphilis, chancroid and other STD in areas with high rates of HIV infection may have a major impact on limiting the heterosexual spread of HIV infection (Kreiss et al. 1988; Piot and Laga, 1989).

2. SOCIOECONOMIC PERSPECTIVES OF PROSTITUTION

Prostitution is essentially a social phenomenon, associated with economic, cultural, moral, behavioural and legal factors. It is dynamic and adaptive requiring the interpersonal interaction of two people - a prostitute and a client. In this transaction the prostitute (or sex worker) is the seller and the client is the buyer of sexual service in exchange for money or things of monetary value, such as drugs or food.

Although not essential in the practice of prostitution, other people may frequently be involved. They include "madams", "pimps" and "procurers". In some countries, prostitution is a part of an organized sex industry. In addition, law-enforcing officers, vice-squad members, health care and social workers, may frequently be in contact with prostitutes and could be important in influencing their behaviour.

The anthropology of female prostitution, comprising its diversity of practices in time and place, the nature of economic dependency as well as an understanding of its relation with "marriage" and the wider kinship, has been recently reviewed (Day, 1988).

2.1 Reasons for entry into prostitution

Economic necessity and financial aspirations are the most important reasons for entry into prostitution both in the developing and developed countries - in the former perhaps simply to survive and in the latter to improve the standard of living and afford the luxuries which the consumer society takes for granted. Some young people might see prostitution as an opportunity to improve their own lives (Potterat et al. 1985). However, many prostitutes are poor and have no alternatives due to lack of education, high

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rates of unemployment, and social isolation from their families and communities. Some of these are school dropouts with little education, some are single mothers who may be abandoned by parents and father of the child. In addition, marital breakdown and parental deprivation may lead to boys and girls abandoning their homes. In the absence of parental or other source of income, and devoid of any skills, they find resorting to prostitution and/or beer selling (Plorde, 1981) as the best alternative to provide for themselves.

2.2 Supply and demand

The migration of people associated with the rapid expansion of towns and cities can lead to an imbalance in the numbers of males and females in the population. This may favour the development of prostitution (Hrdy, 1987; Hunt, 1989). The situation is aggravated by other factors associated with urbanization such as breakdown of family and traditional values, poor housing, unemployment and low wages.

The vast increase in tourism and business travel has increased opportunities for sexual encounters as well as demand for prostitutes, and consequently for global spread of STD. The main highway routes, sea ports, military bases, oil fields, mines and plantations are other places with demand for prostitutes (Carswell et al., 1989).

The young men in certain societies have to accumulate wealth to be able to pay the bride price. Until they have accumulated enough wealth to get married, they may have to resort to prostitutes.

Although the exact numbers involved in prostitution are not known, there could be several thousand prostitutes in some large cities. Financial pressures necessitate prostitutes consorting with multiple partners on a regular or part-time basis.

2.3 Client factors

Clients are more numerous than the providers of sexual services. However, there is no easily recognized "subculture" of customers. Consequently the factors, which lead persons to become clients and thus important to the maintenance of prostitution, are largely unknown. Therefore it is difficult to target health education at this group.

Prostitutes may also be at risk of STD from their non-paying partners, boy friends (Centers for Disease Control, 1987; Day et al, 1988), husbands, etc. Therefore interventions aimed at reducing STD associated with prostitution should also be considered to be directed at this aspect of prostitutes' private lives.

2.4 Types of prostitution and places of work

2.4.1 Prostitution occurs in many forms. Prostitutes may be female or male, and of different ages including children. Prostitutes as well as clients can come from all social and cultural groups.

Prostitution may be a voluntary occupation, but may also be the result of coercion, particularly in child prostitution and the trafficking of women (see 2. 6 and 2. 7). A link between "child sexual abuse" and "child/youth prostitution" has been suggested (McMullan, 1987).

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Some may work only part of the time as prostitutes and others as whole-time prostitutes. The part-timers or intermittent prostitutes indulge in the occupation to supplement their incomes and may stop when the financial circumstances improve. Many of them have other "normal jobs". Some may be married women engaging in prostitution to supplement their husbands' income, without their husbands' knowledge (Ngugi, 1988).

There are high class prostitutes who cater for rich clients and businessmen in the top hotels of the big cities, and the low class prostitutes working in small bars, often in liaison with and servicing taxi drivers, long distance truck drivers and beer sellers.

A considerable number of prostitutes in some cities and countries are women belonging to ethnic minorities.

The locality, the place of work (street, bar, club, hotel, etc.), the sexual services offered, the number of clients served, and the use of protective measures such as condoms, will all affect the risk of STD in clients and prostitutes. For example, the prostitutes who work from certain brothels are required by the establishment managers to be regularly medically examined. Studies have shown that street walkers are more likely to be infected with sexually transmitted agents than call girls and brothel workers (Bess and Janus et al., 1976; Darrow, 1984; Reeves and Quiroz, 1987). As regards sexual practices, in an ethnographic study of AIDS in Brazil it was observed that anal intercourse was frequently practised between men (single and married) and female prostitutes (Parker, 1987). Married men especialy resorted to prostitutes who would perform certain sexual acts which might be shunned by their wives.

2.4.2 Male prostitutes

Male prostitutes are present in most big cities and are sometimes bisexual in orientation, becoming infected and transmitting the disease to their usual female contacts, or becoming infected from female contacts and transmitting the disease to clients.

In Europe there are brothels for homosexual men in some metropolitan cities (Coutinho et al., 1988).

In Africa, where homosexuality is not thought to be numerically important, there are male-prostitutes, operating from bars and hotels, who cater mainly for Asian and European clients, and male and female tourists. Some of them may be school boys wanting to make extra money (Bennett, 1970).

In Singapore, both male and female prostitutes were the largest reservoir of venereal infections (Rajan, 1978). Male prostitutes contributed 469 (20 per cent) of the 2,265 gonococcal infections in all males in 1979 (Rajan et al., 1981).

In the 1970s there were an estimated 250,000 to 300,000 male prostitutes in contemporary American society (Lloyd, 1976). They were usually white, young hustlers ("chickens") or muscular and handsome "call-boys". The hustlers could be found on the streets, public parks, at selected bars or through advertisements in gay newspapers (Darrow, 1986). There were gay auctions in certain health clubs whereby one could have a "slave" at one's disposal for 24 hours.

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A recent study of this group of male prostitutes in Atlanta showed that 27% had antibodies to HIV, 22% and 58% had a seromarker for syphilis and hepatitis B virus infection respectively (Elifson et al., 1989).

2.4.3 Child prostitutes

Sexual exploitation of child labour/working children adds a complex dimension to the problem of sexually transmitted disease/child prostitution. It was observed that children may be sold into the white slave trade or work freelance in certain Asian cities offering sex tours operated from Europe and Japan (Boudhiba, 1981).

A study commissioned by UNICEF draws attention to the commercial sexual exploitation of millions of children in the form of child pornography, child prostitution, child trafficking for sexual purposes and the paedophile problem (Herrmann, 1985). An estimated 2,000 young boys worked as prostitutes in Colombo, Sri Lanka and 40,000 child prostitutes are used in Bangkok, Thailand. About 10,000 young girls are imported to Japan each year for prostitution, and 3,000 young boys worked as prostitutes in the town of Pagsanjan (population 20,600) in the Philippines. There were apparently 8,000 child prostitutes in Paris and the problem had been reported to be severe in Bombay and other big cities of India (Banerjee, 1979), Nepal, Taipei Taiwan (Miller, 1988), Peru, and several other countries. Many children in some of these big cities work as home-helps.

Bond (1981) in a study in Sri Lanka, observed that many of the children used as prostitutes are only 8 years old who have abandoned school. Most came from poor homes; their parents may be separated and one or both of the parents may be dead. These boys sell themselves to the tourists who take them into their hotel bedrooms. The details on how to procure these boys and the payment and the name of hotels to use were advertised in Gay Guides available in Europe and possibly elsewhere.

A subculture of young male prostitutes is known under the nickname of "rent boys". They operate in certain areas of large cities, and offer a variety of sexual practices. However, not much is known about this group, nor on their clients (Morgan Thomas et al., 1989). Many of them are thought to have run away from homes.

The Working Group on Slavery at its Fifth Session (United Nations, 1984) was informed of the tragic situation in parts of north-eastern Brazil where about 50,000 young people struggled to survive in brothels of extreme exploitation.

2.4.4 Traffic in women

According to a recent United Nations Report (1984), there was evidence of a continuous and possibly increasing traffic in young females in and between several countries of the world. This enforced prostitution was a matter of great concern.

2. 5 Mobility

Many prostitutes, some transient, move from one city to another. They may also cross national borders. The influx of prostitutes from Thailand into

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Singapore in 1982 resulted in increased prevalence of Neisseria gonorrhoeae strains with decreased susceptibility to antimicrobials (Sng et al., 1984). In the Dominican Republic, 80 women, tested for HIV infection (38 positive) between 1985 and 1988, had practised prostitution in 27 countries (Koenig, 1989). This mobility also causes difficulty in obtaining proper treatment as well as in contact tracing. In addition, the clientele mobility associated with tourism, air and sea travel, ensures maintenance and spread of infection nationally and internationally.

3. EPIDEMIOLOGY OF STD IN PROSTITUTES

Sexually transmitted diseases are a major health problem in sexually active adolescents and adults in many areas of the world. STD can exist as uncomplicated infections, symptomatic or asymtomatic. Their public health importance is mainly due to the complications and sequelae, such as infertility in males and females, adverse pregnancy outcome affecting both mother and child, neonatal and infant infections, and the new life threatening disease, acquired immunodeficiency syndrome (AIDS).

3.1 Clients

The clients are probably as important in transmitting STD as the prostitutes but their epidemiological characteristics, apart from those who attend special STD clinics, are unknown (see also 2.5).

3.2 Prostitutes as source of infection

Several studies from many countries of all continents have shown that prostitutes are an important source of sexually transmitted infections, much more so in the developing than in the developed countries (Aral and Holmes, 1984; Plummer and Ngugi, 1990). Thus, prostitutes accounted for the various STD in almost half of the infected men seen at STD clinics in Khartoum, Sudan (Taha et al., 1979) and 60 per cent of men in Singapore (Rajan, 1980). At least 70 of the 247 episodes of gonorrhoea and syphilis in men in a semi-urban area of Uganda and 84 per cent of the episodes among university students had been acquired from the bar girls (prostitutes) whose mobility posed insurmountable problems for contact tracing (Arya et al., 1974; Arya and Bennett, 1968). Many of them moved to other areas because of the fear of loss of popularity as a result of infection. At a venereal disease clinic in Butare, Rwanda over 90 per cent of the infected males indicated prostitutes as their source of infection (Meheus et al., 1974). A comparable situation has more recently been reported to exist in Nairobi, Kenya (D'Costa et al., 1985).

It was emphasized that STD, a major health problem in the Philippines, can be correlated with the size of prostitution (Tan and de laPaz, 1987).

In Sheffield, England, of the 1,663 locally acquired gonococcal infections in heterosexual males during 1968 to 1972, 286 (17.2 per cent) were acquired from local prostitutes (Turner and Morton, 1976).

It was estimated that up to 27 per cent of all gonococcal infections in males in Colorado Springs in 1976 were transmitted by prostitutes (Potterat et al., 1979).

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In a recent survey of urethritis in men in Belgium the source of infection in over 60 per cent was a casual partner or a prostitute (Stroobant et al., 1985).

The number of cases of chancroid had been increasing in the United States since 1981 and they were reported to be occurring predominantly among those who consorted with prostitutes (Schmid et al. 1987).

3.3 Prevalence of STD in prostitutes

3.3,1 Bacterial infections

It is difficult to compare data between various studies because of several possible differences in the material and methodology used, e.g. the type of prostitutes, the type of sexual practices (the sample may be unrepresentative of the total prostitute population), the use of preventive measures, differing standards of laboratory methods, and the differing time spans used.

Nevertheless, in settings in which health services are as yet poorly developed or are accessible only to a fraction of the population, prevalence of bacterial STD, which in principle can be effectively treated, remains high in prostitutes (Table 1). Prevalence rates found for instance for gonorrhoea, genital chlamydial infections, chancroid and syphilis often range from 20 to 50 per cent.

Conversely, in the prostitute populations that have access to good quality health services, STD are not more prevalent than in other population groups at risk for STD.

In certain countries, e.g. the United States, where the number of female prostitutes has been said to be declining (Darrow, 1986), the prostitutes contribute disproportionately to STD transmission.

In Singapore, the prostitutes of foreign origin, notably from Thailand and Indonesia, were found to have much higher gonococcal infection rates, respectively 14.7 per cent and 50 per cent, than that (10.6 per cent) in local (Singapore) prostitutes (Rajan, 1980). The same author reported a rise in gonococcal isolation rate in male prostitutes from 7.1 per cent in 1977 to 13 per cent in 1979. Since then, however, the national incidence of gonorrhoea has fallen from 680 per 100,000 in 1979 to 234 per 100,000 in 1987. This degree of fall has almost paralleled that among the registered prostitutes (from 10.6 per cent in 1979 to 4.3 per cent in 1987) (Thirumoorthy, 1988).

Earlier studies among prostitutes had shown gonorrhoea prevalence rates of 44 per cent in Australia (Wren, 1967) and 60 per cent in Brazil (De Amorin, 1966).

Some authors simultaneously surveyed control population of non-prostitutes and found the infection rates to be much lower than in the prostitutes. Thus chlamydial isolation rates of 20 to 31 per cent were found in prostitutes compared with 4 to 9 per cent in control groups (Stary et al., 1982). Likewise, syphilis and gonorrhoea rates of less than 5 per cent were found in the non-prostitute groups, much lower than those in the prostitute groups (Table 1) and the difference was significant (Reeves and Quiroz 1987). These authors also found gonorrhoea and syphilis rates to be significantly greater in street walkers than in any other group.

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Due to inappropriate use of antibiotics, gonorrhoea, and, to a lesser degree, chancroid, have become resistant to the widely available and lower cost antibiotics such as the penicillins, sulfonamides and tetracyclines. Alternative treatment regimens are generally more expensive and often not readily available.

3.3.2 Penicillinase-producing Neisseria gonorrhoeae (PPNG)

Auxanographic and plasmid typing have shown that prostitutes play an important part in the spread and epidemiology of PPNG (Ansink-Schipper et al., 1984). One of the factors considered to have facilitated the spread of PPNG is chemoprophylaxis which is often practised by the prostitutes. In a study of Philippine hostesses infected with N. gonorrhoeae it was estimated that about 16 per cent indulged in self medication with antibiotics (Westbrook, 1980). Likewise inhibitory substances were detected in the urine of 21% of the prostitutes in Singapore (Goh et al., 1984). Although chemoprophylaxis did reduce the risk of gonococcal infection, it was also associated with high risk of PPNG infection.

3.3.3 Viral infections

Prevalence of HIV infection among prostitutes ranges from zero in some areas to over 80% in others (Padian, 1988; Anonymous, 1989). These data must be interpreted with caution, as in most surveys a convenience sample, which is often biased towards street workers, rather than a representative sample of prostitutes, has been studied.

In addition, the importance of other incurable sexually transmitted viral infections, such as those due to herpes simplex virus, hepatitis B virus (HBV) and human papilloma virus (the latter two on account of their causal or associated risk with cancer), is being increasingly recognized. Prevalence of these conditions is also relatively high in prostitutes (Table 1). If prostitutes or their sex partners are injecting drug users and share needles or syringes, this is an additional risk factor for acquisition and subsequent transmission of HIV and HBV infection.

In Greece, a comparative study of the prevalence of anti-HBs among 293 prostitutes (Table 1) and a control group of 379 pregnant women matched for age and socioeconomic status showed the anti-HBs positive rates to be 56.7% and 24.5% respectively; the difference was significant (p <0.001) (Papaevangelou et al, 1974). On the other hand in Mogadishu, Somalia no significant difference was found between the various groups for hepatitis B infection rates, being 20% in prostitutes and 22% in non-prostitute educated women (Jama et al., 1987) .

A new addition to the continuously increasing number of sexually transmissible viruses is adult T cell leukaemia virus/human T-cell lymphotropic virus type 1 (ATLV/HTLV-1) (Bartholomew et al., 1987; Kajiyama et al., 1986).

3.3.4 STD in child prostitutes

There is a paucity of information on STD in child prostitutes. In a study of 80 female child prostitutes (~ 15 years old) in Bombay, India, evidence of syphilis (positive VORL test) was found in 54 (67%) (Bhalerao, 1985).

3.3.5 Time-reinfection relationships

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To plan appropriate intervention strategies, it is important to collect information on the time - re-infection relationship in which the number of clients a day is an important determinant. In a gonorrhoea reinfection study in Nairobi, Kenya, 97 women were followed-up for one to three months; 43 women acquired new infections: the mean time to acquisition of a new infection was 21 days (range, 2 - 91 days). In addition, at least eight women had a second reinfection and two had a third reinfection (D'Costa et al, 1985).

A study of the relation of frequency of sexual intercourse to infection showed a 1.3% increase in gonorrhoea rate with each additional daily contact (Leeb et al., 1978).

In a survey of prostitutes in Fresno County, California, repeat gonococcal infections were reported among 19 (7.5%) of the 253 women who attended on at least two occasions. Of these 19 women, 14 had been infected twice and five were infected three times, during the study period of one year (Jaffe et al., 1979).

In the study of 60 prostitutes in Sheffield, England, covering a 5-year period the average number of gonococcal infections was 2.4 (Turner and Morton, 1976).

If a prostitute has about five sex partners daily i.e. 35 per week, in a town with high prevalence of STD, then she is very likely to get infected sooner than later, and capable of infecting many people in a short period of time. This aspect of sex work will need to be considered in the timing of intervention strategy.

4. BEHAVIOURAL ASPECTS

4.1 Knowledge of and attitudes towards various STD. preventive measures. and their use

Knowledge and attitudes towards STD, preventive measures, and the use of these measures vary considerably not only from country to country, but also between subgroups in a population.

Among groups of prostitutes and clients where awareness exists of the risks and complications of STD, people usually are concerned about their health. Whether or not attempts are then made to prevent disease depends on the knowledge about preventive measures, and on the availability of these measures.

However, it is recognised that in many parts of the world this awareness is lacking, as is knowledge about possible ways of preventing STD, including HIV infection. In some cases the awareness or the knowledge might be erroneous, and so lead to the adoption of inappropriate measures. Often there are serious constraints which do not allow the adoption of risk reducing behaviour. Such a constraint could be the unavailability of condoms, or a lack of awareness on the part of the client, who then does not accept the use of a condom.

There are also specific social and behavioural constraints which make risk reduction in the sexual activities of prostitutes with their non-paying regular

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sex partners more difficult to achieve. Very few prostitutes use condoms with their regular partners.

This indicates that promotion of risk reducing behaviour involves not only education and information to raise the level of awareness and knowledge among both prostitutes and their clients, but also needs to address possible constraints to the adoption of such behaviour. It has been shown that positive changes in the preventive and health seeking behaviour of prostitutes can be brought about (Ngugi et al. 1988).

4.2 Health seeking behaviour

The extent to which a person with a STD seeks medical help is dependent on a number of factors. Awareness of the risks and complications of STD is necessary. Information about preventive measures and about where to seek help should be accessible and acceptable, as should be clinical facilities for diagnosis and treatment. The accessibility and acceptability of clinical facilities itself depends on a number of factors of which the financial cost to the patients, the distance to be travelled, the waiting time, staff attitudes, and opening hours should especially be mentioned.

Many people (including prostitutes and their clients) have tendency to use methods of STD prevention and treatment which are unsafe and of unproven efficacy. These include the use of herbs, topical ointment, "miracle drugs" and other forms of traditional medicine and quackery. Even more harmful is the practice of self medication which usually involves taking inadequate dosage of often inappropriate antibiotics. This not only leaves the person remaining untreated who may continue to spread the infection and/or develop complications, but may also result in the emergence of antibiotic resistance. These practices should be strongly discouraged and adequate treatment facilities should be made available.

Prostitutes and clients who have asymptomatic infections will not seek treatment for these infections. The need for regular health care should be stressed to these groups at a high risk for acquiring STD. In this way asymptomatic infection can be detected and treated before complications or transmission may arise.

The seeking of medical help for STD offers a good opportunity for education and counselling on the adoption of risk reducing measures.

5. PRIMARY PREVENTION

5.1 STD education

Prostitutes and their sexual partners do not wish to become infected with any of the STD. Furthermore, they do not want to transmit infections to their sexual partners or unborn children. Many are highly motivated to reduce their risks of infection, but lack awareness of the various methods of prophylaxis available or have not been given instruction on how to avoid exposure to STD. STD educational programmes have been designed and implemented to help prostitutes and their sexual partners avoid STD infection (Alexander, 1988; Darrow, 1988).

5.2 STD educational programmes for prostitutes

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To be effective, STD educational programmes must be based on openness, honesty, and respect because everyone responds to attention, acceptance, and recognition. Furthermore, these programmes recognize that persons involved in prostitution can have greatly different interests and characteristics. Approaches and materials developed for one target group may be inappropriate or offensive to another. Therefore, baseline research can be extremely helpful in identifying the target groups, establishing disease prevalence and levels of knowledge about STD prevention, and in suggesting effective communication of initial messages.

STD education begins with clear, simple and accurate messages targeted for specific audiences. Additional information can be provided in increments to promote an accumulation of knowledge and changes in behaviour, and finally to achieve a significant reduction in STD incidence.

Messages should be simple and to the point (e.g., Let's Stop AIDS) (Siegel et al. 1986). They should appeal to self-interests (e.g., protect yourself) in addition to altruistic motives (e.g., protect your children and others that you love) (Weinstein, 1987). If the message provides a threat (e.g., AIDS can kill you), the threat should immediately be followed with an explicit description of how to counter the threat (e.g., but AIDS and other STD can be prevented by avoiding direct contact with the blood, semen, and other infectious body fluids of persons who are infected) (Job, 1988). The message should be stated clearly in language that target group members can understand and should be followed with information about how more specific questions or other concerns can be addressed.

Although public health officials may have good ideas about the information they want to be disseminated, they often have incomplete or prejudiced notions about how messages should be delivered. Those with experience with prostitution usually have easier access to high-risk populations and may be able to more effectively communicate with them than public health officials. Most importantly, behaviour change is most likely to occur when prostitutes and their sex partners are actively involved in STD prevention efforts. Prostitutes (including ex-prostitutes) have been effectively used as counsellors and members of self-help groups (Alexander, 1988., Ngugi et al, 1988).

5.3 Evaluation

Continual evaluation should be carried out to identify which interventions are successful in conveying information and facilitating behaviour changes such as condom use and other safer sex practices, and whether or not the disease incidence has decreased as a result of the programme.

The evaluation steps include:

1. baseline data before full-scale intervention 2. ascertainment at scheduled intervals for:

(a) execution of programme as planned (process evaluation) (b) change in knowledge, beliefs and behaviour as intended (impact

evaluation) (c) STD incidence (outcome evaluation).

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5.4 Methods of primary prevention

Three methods of primary prevention ("safer sex") are available to prostitutes and their sex partners. First, prostitutes and their partners can engage in non-penetrative sexual activities. Second, prostitutes and their partners can reduce their risks of STD transmission by properly and consistently using condoms during sexual intercourse. Third, prostitutes and their sex partners might be able to reduce their risks of infection with certain sexually transmitted pathogens by properly and consistently using spermicides during sexual intercourse, but further studies to establish effectiveness in this area are necessary.

Non-penetrative sex

In some areas, prostitutes and their clients are becoming more interested in sexual activities that do not involve insertion of the penis into the vagina, rectum, or mouth because of recent publicity and concern about infection with HIV, herpes simplex virus, and other STD that cannot be treated with antimicrobial agents. These "safer" sexual practices include masturbation and other activities that do not involve exposure to semen, blood, or vaginal fluids. Educational efforts to adopt these "safer" sexual practices have been successful in some populations involved in prostitution.

Condoms

When used properly and consistently, latex condoms have been shown to reduce the risk of STD transmission (Mann et al, 1986, Smith and Smith, 1986, Centers for Disease Control, 1988). However, prostitutes and their clients in some setings have been discouraged or prohibited from using condoms. In some areas in Africa, the condom use for family planning or STD control was thought to be no more than 1% (Anonymous, 1989). Recently efforts have been initiated to make condoms more widely available and acceptable to prostitutes and their sexual partners. In addition, advice for these groups on the correct method of use of condoms can reduce the risks of condom failures due to breakages or leaking. These and other issues such as working out a strategy to persuade the non-paying partners to use condom could also be discussed at self-help groups or workshops for prostitutes and their regular sex partners.

Advice should also be given on the hygienic disposal of used condoms.

Further development of condom design is required, including improvements in its strength, the availability of different sized condoms and the form of lubrication.

Female condoms and new types of tampons/diaphragms are under investigation.

Spermicidesjchemoprophylactics

Many chemicals have been shown in vitro to kill sperm, bacteria and viral pathogens (Singh et al., 1972 and 1976, Stone et al., 1986), but only a few have been adequately tested in humans to evaluate their effectiveness (Louv et al., 1988). Multiple factors contribute to the vaginal environment and must be considered when assessing the potential value of spermicides. The concentration of spermicides, mode of utilization (gel, foam, or tablet), and difficulties in assessing user compliance with recommendations further complicate efforts to assess the usefulness of these substances.

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Field studies of intravaginal spermicides show that they are generally acceptable to women and their sex partners, but few studies have been able to clearly establish prophylactic or cost-effective benefits to STD control. Nonoxynol 9, a surfactant and the active ingredient of several spermicides, has been extensively investigated. In vitro studies have shown that it inhibits N. gonorrhoeae and Treponema pallidum (Singh et al., 1972a), Chlamydia trachomatis (Benes and McCormack, 1985; Kelly et al. ,'1985), Trichomonas vaginalis (Singh et al., 1972b), herpes simplex virus (Ascilai et al., 1978; Singh et al., 1976) and HIV (Hicks et al., 1985; Malkovsky et al., 1988).

In a study of endocervical infection among prostitutes in Bangkok, Thailand, it was demonstrated that nonoxynol 9-impregnated contraceptive sponge users were less likely to become infected with chlamydia and gonorrhoea (Rosenberg et al., 1987). The additional advantage is that the spermicide can be used independently of the sexual partner. However, the effectiveness of this method is dependent on such factors as motivation and acceptance. Besides, intravaginal spermicides may not prevent infection of the urethra and Bartholin ducts.

Nonoxynol 9 has been recommended to be used along with condoms, as a measure to inactivate HIV in genital secretions. However, further research is needed to demonstrate its effectiveness and to confirm that it does not have any deleterious effect on local immune defenses and that it does not damage the genital tract epithelium rendering it more permeable to HIV (Jeffries, 1988). Moreover, its safety in rectal use is not established (Rietmeijer et al., 1988). Its systemic absorption too needs to be investigated. Other spermicides such as the widely used benzalkonium chloride or menfegol must also be judged by similar criteria.

Information is also needed on their use in the prostitute - multiple partner encounter - situation, as regards form, frequency and safety in the event of protracted and frequent applications.

6. EARLY DETECTION OF STD

Screening can be an effective STD detection strategy in populations such as prostitutes and their clients. Screening programmes can also assist programme directors to establish baseline data for STD prevalence in these populations in order to develop appropriate intervention strategies.

Issues to be carefully considered before a disease detection programme is established include identification of target populations, potential benefits, costs, acceptability of the programme, and reliability of laboratory tests (Meheus and Piot, 1986., WHO, 1985).

Disease detection programmes for STD control should only be instituted if facilities for appropriate STD management are available.

The value of these disease detection programmes lies in finding asymptomatic treatable infection before progression to complications, and the interruption of further transmission.

These programmes can be of considerable benefit in bacterial STD infections such as gonorrhoea, chancroid, syphilis and chlamydia, all of which can be cured. Other information such as antimicrobial resistance, disease trends, knowledge of STD and of preventive measures can also be gathered.

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6.1 Reinfection rate

An intervention in the prostitute reservoir will have to take into account the reinfection rate. A simple model has been elaborated based on 35 contacts/prostitute/week, 50% prevalence of gonococcal infection and 20% chance of infectivity (D'Costa et al., 1985). They surmise that intervention at three week intervals would be necessary for the programme to be cost-effective. They do not suggest, however, as to how the prostitutes are to be persuaded to attend and the mechanisms of registration, compliance, etc.

6.2 Cluster testing

Cluster testing of night clubs and other similar places might be cost-effective, but will be difficult in the case of the street corner girls, the call boys, the call girls and other mobile prostitutes of no fixed address.

There is no universally accepted single method to motivate this group of sex workers to attend for screening.

6.3 Walk-in clinic

A walk-in clinic in the red light area or in another suitable part of the city is one of the alternatives for those not wanting to attend a STD clinic of the "establishment". The clinic should be appropriately equipped and staffed by carefully selected people without judgemental approach. To seek co-operation of prostitutes it may be rewarding to work through an appropriate local prostitute-support organization. The clinic could also provide other services such as free supply of condoms, free syringe exchange scheme, HIV testing, breast cancer screening, general practitioner service, welfare rights, etc.

6.4 Outreach approach

One way of reaching this population is to attach a social worker (or a suitably trained prostitute or ex-prostitute) to the area where most prostitutes live, as happened during a survey in Sheffield, England (Turner and Morton, 1976). The "social worker" could inform them of the meaning of the current legislation, counsel them on contraception, the use of condoms, the possibility of contracting sexually transmitted diseases and therefore the need to be checked at the local clinic.

6.4.1 Mobile van clinic

Outreach to street prostitutes may include a mobile van clinic for examination and treatment, a supply of condoms, spermicides and other educational material for distribution, and facilities for coffee and discussion.

The outreach programmes have been effectively used (Jaffe et al, 1979., Alexander, 1988) but need further evaluation in different settings.

6.5 Management

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Treatment of bacterial disease should always be combined with counselling with regard to treatment compliance, follow-up for tests of cure, and adoption of risk reducing behaviours. For viral infections, where no treatment is available, counselling to prevent transmission is essential.

It is recommended, whenever possible, that diagnostic, treatment and educational services can be organized to occur at the same visit. These persons are unlikely to attend more than once if a single visit will do.

In addition, for addicted prostitutes, facilities should be made available to manage their addictions.

Regular attendance should be encouraged on a voluntary basis and as a health seeking behaviour.

The imposition of legal sanctions are considered to be counter productive and will discourage cooperation from high-risk groups such as prostitutes in further control efforts. In most jurisdictions public health laws and regulations exist which will cover extreme cases not amenable to health intervention measures.

7. SYSTEMIC CHEMOPROPHYLAXIS INCLUDING SELECTIVE MASS TREATMENT

7.1. Systemic chemoprophylaxis, and selective mass treatment, i.e. treatment of high risk groups such as prostitutes, are administered without making a diagnosis.

In many parts of the world, especially in developing countries, antibiotics are readily available without prescription and widely abused by self-medication. Attention has been drawn to some of the hazards of this practice (3.3.2 and 4.2).

The advisability of the use of antibiotics to prevent illnesses, such as STD, for which other preventive measures are available has been questioned (Sack, 1979). Nevertheless, in certain situations comprising high prevalence of STD, inadequate or non-existent laboratory facilities, itinerant population, mass treatment of high risk groups has been suggested as substitute for early detection. However, mass campaigns using total or selective mass treatment have not been applied to any significant extent against STD mainly because reintroduction of disease may quickly result in reversal of any gains made. The latter is almost inevitable in the case of prostitutes who will need to be surveyed periodically and mass treatment policy reviewed or repeated accordingly.

The programme must be cost effective and that demands a thorough understanding of the epidemiology of the disease.

In addition, the treatment regimen chosen must be acceptable to the targeted population otherwise the compliance may be low. This was indeed the case with PAM (procaine penicillin with aluminium mono stearate) used to control syphilis in prostitutes in Indonesia. Because of the pain associated with the injection, compliance was no more than 15% (Soewarso, 1988).

WHO/VDT/89.446 Page 18

7.2 Diseases suitable for selective mass treatment

No safe, curative, systemic chemotherapeutic regimen is available for viral STD. Of those caused by bacteria, gonorrhoea and chancroid with short incubation periods merit consideration (chlamydia! infections are unsuitable because of the need for multiple dose regimens over several days which may cause compliance problems). Concurrent HIV infection may impair response to treatment. The recommended treatment regimens should, therefore, take into account HIV infection status of the relevant population group.

7.2.1 Gonorrhoea

Systemic chemoprophylaxis against gonorrhoea can be effectively applied especially as a temporary measure provided the drug regimen chosen is appropriate as regards the antimicrobial susceptibility of the circulating strains.

For instance, 200 mg minocycline administered, under supervision, to sailors after sexual intercourse with prostitutes reduced the infection rate by 58% (Harrison et al., 1979). There was no reduction, however, in the incidence of infections caused by highly resistant strains of Neisseria gonorrhoeae. In addition, the incubation period nearly doubled among men who became infected with moderately resistant strains. This practice could, therefore, result in increase in the number of asymptomatic carriers as well as in the selection and spread of resistant strains.

Most of the effective treatment regimens are likely to be expensive. In addition, the treatment chosen should not only eradicate the infection in the genitals but also from the extragenital sites. The newer quinolones, as regards the latter aspect as well as cost, appear promising with the added advantage of being single-dose oral regimens. At the time of writing, emergence of gonococcal strains with decreased susceptibility to ciprofloxacin, currently the most active of the 4-quinolones against N. gonorrhoeae, had been reported (Gransden et al., 1990; Jephcott and Turner, 1990).

Another important consideration which will have a bearing on the choice of appropriate intervention strategy is the time-reinfection relationship (see 3.3.5 and 6.1).

7.2.2 Chancroid

Chancroid is endemic in many tropical areas and outbreaks have also been reported in the developed countries (Blackmore et al., 1985). The infection is also commonly encountered in prostitutes (D'Costa et al., 1985), and has assumed a great importance because of the significant association between HIV infection and genital ulcer disease (Simonsen et al., 1988). Control of this and other causes of genital ulceration should, therefore, be legitimate, indeed essential target for intervention activity.

The drug regimen to be used will need to take into account the considerable geographical variation in the antimicrobial sensitivity of H. ducreyi. Significant resistance to tetracycline, streptomycin, sulphonamides and more recently to trimethoprim and chloramphenicol have been reported. Trimethoprim/sulfametrole 640/3200 mg as a single dose has been found to be effective in Nairobi, Kenya (Plummer et al., 1983) but not in Thailand (Taylor et al, 1985). The newer quinolones appear promising but

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multiple doses might have to be used (Naamara et al., 1988). In particular this could be the case in patients with chancroid who are also infected with HIV (Cameron et al, 1988).

7.3 In conclusion, systemic chemoprophylaxis including mass treatment as STD control measure remains highly controversial. The following factors should be considered and the conditions met when planning and before implementing this approach for the prostitutes:

(i)

(ii)

(iii)

(iv)

(v)

confirm high prevalence of the specific infection in the prostitutes;

confirm acceptance of the mass treatment of the group;

consider carefully the benefits as well as limitations (e.g. risk to the community) of the regimen to be used. This necessitates a full appraisal of the STD pattern including prevalence of concurrent infections;

establish the time-reinfection relationship in order to assess the need to repeat mass treatment. This strategy involving repeated administration of drugs may necessitate consideration of biological implications;

assess in a pilot study the effectiveness of mass treatment in terms of cost and infection rate as compared with organized disease detection programme;

(vi) chose the drug regimen which is highly effective, cheap, administered preferably in a single dose (to ensure compliance) and safe.

7.3.1 In settings where health care facilities are inadequate and if prevalence of gonorrhoea or chancroid is confirmed to be high in prostitutes, a mass treatment programme may be instituted as a temporary measure.

7.3.2 The disadvantages of mass treatment include: unnecessary treatment of persons without infection, possible side effects, and potential for the development of antimicrobial resistance. Therefore, priority must be given to develop adequate facilities for management and prevention of STD.

8. THE ROLE OF LEGISLATION

Prostitutes have attracted the attention of sociologists, moralists, politicians and health administrators, probably for several hundred years. STD control provisions in many countries are encountered in the legislative texts dealing with the control of prostitution. It is not generally clear as to what contribution these provisions have made to STD control.

8.1 Control of prostitution

Several methods have been tried to control prostitution but without much lasting success.

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The general measures include: stabilization of marriage, marriage counselling, education of children about family life and of the public to uphold traditional and religious values, hostels for young girls, measures to reduce unemployment and training programmes, equal job opportunities for women, and rehabilitation of prostitutes by developing and implementing educational programmes and providing alternative occupational opportunities.

The specific measures which have been applied include repatriation and legislation. One example of the former is the repatriation of Luo girls practising as prostitutes in Mombasa in the hope that after returning to their homes, the tribal and family pressures will discourage them continuing in the profession (Bennett, 1970). Over one hundred years earlier, in the United States, attempts to deport Nashville women "publicly known to be of vile character" culminated in licensed prostitution with regulations for weekly examinations, certificates of freedom from disease and a hospital for those diseased (Kampmeier, 1982).

8.1.1 Legislation to control prostitution

Several countries have made attempts to control prostitution by legislation which has generally reflected a moralistic view, but without success. Prostitution has continued to flourish throughout the world. This being so, the society has had to tolerate it as "necessary evil" (De Graaf Stichting and Visser, 1988) leaving scope, however, for police harrassment. The prostitutes may be arrested and fined for being a nuisance to the public order.

It is widely believed that these suppressive methods hindered control because they encouraged clandestine prostitution, thus contributing to spread of STD (Willcox, 1964; King et al., 1980). This phenomenon had earlier been observed when it was reported that gonorrhoea and syphilis had in fact increased among women arrested for prostitution in New York after the illicit houses had been closed (Rosenthal and Kerchner, 1948). Noted also was the replacement of prostitutes by the promiscuous amateur (Rosenthal and Vandow, 1958).

8.1.2 Legislation for compulsory screening

Whereas some experts believe that legislation for compulsory screening may be counterproductive and may encourage clandestine prostitution, others have found the system to be effective in their respective areas. For this method to be meaningful, some sort of registration of prostitutes is essential. Some prostitute groups consider enforced screening to be an infringement of human rights unless the clients are also required to go through a similar procedure.

In Singapore, for example, a medical scheme was launched in 1976 (Rajan, 1978 and 1982). It was backed by legal authority and subtle legal pressure to ensure compliance. The persons, male and female allowed to practise prostitution had to fulfil three criteria:

(a) to be above the age of 18

(b) to carry a medical card to be updated every two weeks after medical examination

(c) to practise his or her activity in a designated area.

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The subjects were screened for gonorrhoea (culture) every two weeks and for syphilis (serology) every three months. More recently other tests, including those for HIV and chlamydia infections, and cervical cytology, have been added (Thirumoorthy, 1988).

The scheme included elaborate system of information, treatment and recall. The scheme was well accepted by the prostitutes (5,000) with almost 90 per cent compliance. The incidence of gonorrhoea and syphilis declined (respectively by one third and one half) in the female prostitutes. The reasons for high compliance, according to the author, were: lack of legal compulsion and avoidance of punitive pressure, at the same time harrassing the keeper of the brothels until there was 100 per cent compliance.

In Taipei (Taiwan), prostitution is legalized. All prostitutes are registered and have a registration number. They are required to be screened weekly. Those with positive (gonorrhoea) culture are recalled for treatment. Three days later, this is followed by a repeat culture and thereafter the weekly screening is resumed (Leeb et al., 1978).

In Vienna (Austria), the licensed prostitutes are obliged to attend for their weekly test, otherwise they lose their licence (Fanta et al., 1979).

In Tasmania (Australia), the Public Health (Venereal Diseases) Regulations 1966 forbid issuing of a certificate of freedom of venereal disease to any person whom the medical practititioner knows or suspects to be a prostitute (WHO, 1975).

In Panama, prostitution is regulated by legislation and weekly screening for STD is mandatory in social hygiene clinics. Compliance is monitored and those women and businesses defaulting are fined. These measures help to provide data which are used to adjust control strategies (Reeves and Quiroz, 1987).

In Colorado Springs, USA, the risk for prostitutes of contracting gonorrhoea decreased after the control measures which included the use of legal orders based on the constitutional requirement of "least restrictive alternative" were rigorously applied (Potterat et al., 1979). The population subjected to this legal system must have a demonstrably increased risk of sexually transmitted disease. The woman after having been served with the health-hold order is detained until the Health Department representative makes a ruling as to the likelihood of venereal disease.

In Atlanta, USA, under Section 54-121 of Fulton County Health Regulations, those arrested for prostitution or other related sexual offences are obliged to be screened for STD at the Fulton County Health Department. If they fail to report to the health department, they are considered guilty of a misdemeanour (Conrad et al., 1981). The authors claimed that this procedure was effective in their community and recommend evaluation of the system elsewhere.

Others, however, believe that laws demanding registration and mandatory examination and testing for STD (including HIV infection) are counterproductive. They may encourage people at risk to avoid medical attention because of the fear of repressive actions if found STD positive. A two-tier system may thus result, in which the unregistered prostitutes, likely to include illegal immigrants, under-age workers and injecting drug users, may remain at greater risk of infection (Day, 1988). There is also the risk that

WHO/VDT/89.446 Page 22

STD-free certificates may engender false sense of security, thereby discouraging safer sexual practices both by the prostitute and the client. In addition, the freedom from STD may have been based on tests by a substandard laboratory, or false negative reporting while the person was in incubation stage, or due to some technical or sampling error.

8.2 International instruments

The traffic in persons and exploitation of the prostitution of others have been matters of great international concern and have resulted in a number of international instruments (United Nations, 1988):

(i)International Agreement for the Suppression of the White Slave Traffic (1904) as amended by the Protocol approved by the General Assembly of the United Nations in 1948;

(ii)International Convention for the Suppression of the White Slave Traffic (1910), as amended by the above Protocol;

(iii)International Convention for the Suppression of the Traffic in Women and Children (1921) as amended by the Protocol approved by the General Assembly of the United Nations in 1947;

(iv)International Convention for the Suppression of the Traffic in Women of Full Age (1933), as amended by the aforesaid Protocol;

(v)Convention for the Suppression of the Traffic in Persons and of the Exploitation of Prostitution of Others, adopted by the United Nations General Assembly in 1949.

The United Nations Convention of 1949, ratified by many countries, aimed to reduce the exploitation of women by organized prostitution and agreed not to register prostitutes, and to ban living on the earnings of prostitutes.

The World Conference of the United Nations Decade for Women: Equality, Development and Peace (1980) considered "that traffic in women and children forced into prostitution remains a continuing evil", and deplored "the scant interest shown by governments and international organizations in this serious problem", further reminded "Governments that women and children prostitutes have the right to legal protection against maltreatment which they may be subjected to for the sole reason of their being prostitutes".

9. RESEARCH PRIORITIES

9.1. Epidemiology and behavioural aspects

The limited knowledge on the epidemiological and socio-cultural aspects of STD in prostitution is a constraint on the design of appropriate methods of control.

Studies are needed on the incidence and prevalence of STD, including the time-reinfection relationships, in different types of prostitutes, taking also

WHO/VDT/89.446 Page 23

into consideration the sexual practices, injecting drug use, and use of STD prevention measures. These data will provide the basis for the formulation of control and evaluation programmes.

Information is also required on the knowledge of, and attitudes of prostitutes towards: various STD, their respective preventive measures, and the use of these preventive measures, as well as the use of local clinical facilities, so as to design the relevant health education and STD management programmes.

Priority should be given to collect more accurate knowledge on child prostitution and reliable data on STD in child prostitutes.

There is an urgent need to know the factors which lead persons to become clients, to facilitate targeting of health education efforts at this group.

9.2 Diagnosis and treatment aspects

Despite considerable progress in the last few years on the diagnostic techniques, development of simple, cheap, rapid and reliable diagnostic tests for STD, which could be carried out in field conditions, should continue.

Further studies on single or short-term treatment regimens, preferably effective against common concurrent STD, are indicated.

9.3 Prevention and control

There is an urgent need to develop education programmes, including outreach methods, aimed at prostitutes and clients, in the use of safer sex and safe injecting drug practices at all times. These programmes should include evaluation to ascertain intended change in behaviour and the outcome in terms of STD incidence. Serious consideration should be given to the involvement of current or ex-prostitutes in the design and implementation of these programmes.

Further research is needed into the design of condom, including improvements in its strength, availability of different sizes, acceptability, and the form of lubrication.

Work should continue on the study of spermicides as regards their safety, use-effectiveness and mode of utilization in STD prevention.

The role of systemic chemoprophylaxis including selective mass treatment in the STD control in prostitution remains to be clarified. Any such scheme will need careful planning, meticulous implementation and thorough evaluation.

10. RECOMMENDATIONS

10.1 Recommendations to Member States

1. The potential for prevention and control of Sexually Transmitted Diseases (STD) in prostitution should be recognized as a priority and be part of a comprehensive national STD control programme. WHO has produced detailed

WHO/VDT/89.446 Page 24

and practical guidelines for such a programme. All governments are urged to review their STD programmes and initiate improvements where appropriate. The programme should comprise in particular the development of a national STD reference centre, adequate diagnostic, treatment and educational facilities, and professional training in control measures of all health workers, including those at the primary health care level.

2. Member States are urged to review their policies in regard to prostitution. An empathetic approach, and avoidance of discrimination against people engaged in prostitution will improve their co-operation in activities aimed at prevention and reduction of STD. Educational and clinical facilities should be accessible and acceptable to this group of people.

3. Member States should go ahead with the implementation of primary prevention programmes. These programmes may involve current or former prostitutes as educators and counsellors to help prostitutes and their partners avoid sexually transmitted infections. Furthermore, Member States must continue to make efforts to develop and improve the health care facilities including clinical and laboratory services.

Concerted action between STD control programmes and HIV/AIDS prevention programmes should make the fight against these conditions more cost-effective. Mutually supportive, such programmes will be maximally effective.

4. Member States are urged to support research into the magnitude and the nature of the problem of STD in prostitution and into an evaluation of the prevention and control programme in changing behaviour and reducing STD.

10.2. Recommendations to WHO

1. WHO should assist Member States to implement programmes on STD control in prostitution as outlined in this document by providing technical support and guidance.

2. WHO should promote and support research activities regarding epidemiological, behavioural, legal and other issues related to STD in prostitution.

3. WHO should foster the implementation of operational research on STD control strategies in prostitution, in particular impact of educational programmes, screening and case-finding strategies and selective mass treatment.

4. WHO should promote consensus building in relation to the utility or otherwise of controversial approaches to STD control in prostitution (e.g. decriminalization of prostitution, incarceration and forced treatment).

5. WHO should together with its regional offices organize:

(a) training courses to improve skills of health workers in the various aspects of STD prevention and management;

(b) consultative meetings to develop international co-operation in the surveillance and control of STD.

6. WHO should support and coordinate research activities on the effectiveness, in STD control, of intravaginal spermicides and chemoprophylactic agents, including their potential effects on the foetus.

ll. SUMMARY AND CONCLUSIONS

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Prostitutes and their clients have attracted tne attention of health authorities for a long time because of concern over their role in the spread of sexually transmitted diseases (STD). This concern has become more urgent because of the advent and worldwide spread of HIV infection which is mainly transmitted sexually and is incurable.

In addition, infection rates for gonorrhoea, chlamydial infections, chancroid and syphilis often range from 20-50% in prostitutes. Complications and sequelae such as pelvic infection, ectopic pregnancy, infertility, and congenital and neonatal infections are also common. The importance of other sexually transmitted viral infections such as those due to herpes simplex virus, hepatitis B virus and human papilloma virus, (the latter two on account of their causal or associated risk with cancer), is being increasingly recognized.

The vast increase in tourism and business travel has increased opportunities for sexual encounters as well as demand for prostitutes, and consequently global spread of STD.

The ultimate goal with regard to prostitution should be to offer women, men, and children realistic alternatives, so that they will not be induced into prostitution, neither by a person, nor by economic or social circumstances. The United Nations (1986) urged Member States to direct resources towards providing economic opportunities including training and employment among steps for the prevention of prostitution. However, the socio-economic realities of life in many countries are likely to continue to favour the existence of prostitution and consequently the opportunities to spread STD. In most countries, because of inadequate health services, this results in continuing spread and maintenance of STD at high levels. Intervention in this situation, if successful, could prove to be an effective means of STD prevention and control.

Since economic motives are the main reason for entry into prostitution, to prohibit prostitution by law (in the presence of demand, equally compelling, for this service) without creating job opportunities for women and men at risk for prostitution and offering prostitutes an alternative work as a source of income, is destined to failure. Indeed, such steps are driving prostitution underground - thus making STD control difficult. Nevertheless, reducing the risks associated with prostitution, abolishing forced prostitution, and by offering training for other occupations to those who want to leave, may be long-term goals. At th~ present time, however, urgent and realistic intervention measures must be taken to reduce and control STD in prostitutes. Medical, technological and educational services should be made available to institute cost-effective programmes.

Very little will be achieved, however, without the participation of the prostitutes themselves in STD prevention efforts. They, just like everybody else, value their health. When given the right opportunities, prostitutes, in general, want to work under "safer-sex" conditions. An empathetic approach including decriminalization of prostitution is more likely to succeed with regard to STD reduction than attempts to abolish prostitution and compel prostitutes to undergo screening by punitive and harsh legislation. The latter measures in practice are unenforceable and have proved to be counter-productive.

Avoidance of discrimination against people engaged in prostitution will improve their cooperation in activities aimed at reduction of STD.

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Primary prevention programmes (STD education, adoption of safer sexual practices including use of condoms), which may involve current or ex-prostitutes as counsellors, should be implemented to help prostitutes and their sexual partners avoid STD infections.

Screening programmes to detect STD early in asymptomatic persons can be of considerable benefit but cannot be instituted without adequate facilities for the appropriate management of these infections.

Selective mass treatment for gonorrhoea or chancroid may be instituted as a temporary measure. However, priority must always be given to develop adequate facilities for the prevention and management of STD.

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TABLE 1. PREVALENCE OF SEXUALLY TRANSMITTED DISEASE IN PROSTITUTES*

REFERENCE DISEASE PLACE METHOD NUMBER NUMBER STUDIED POSTIVE (%)

Arosemena et al Human papilloma Panama HPV 16-18 183 31 (16.9) 1987 virus infection Cervix

Conrad et al ~ Gonorrhoea Atlanta Cervical 237 47 (19.8)

1981 (USA) culture Females Trichomoniasis Wet mount 237 25 (10.6)

Syphilis " VDRL,FTA-ABS 237 8 (3.4)

~ Gonorrhoea " Ureth.smear 34 5 (14. 7)

Males Syphilis " VDRL,FTA-ABS 34 5 (14.7)

D'Costa et al Gonorrhoea Nairobi Cervical 193 90 (46.6) 1985 (Kenya) culture

Syphilis " RPR,TPHA 193 80 (41.4)

Chancroid " Culture 193 10 (5.2)

Denis et al Syphilis Ivory Coast TPHA 232 109 (47) 1987

Fanta et al Gonorrhoea Vienna Culture 548 199 (36.3) 1979 (Austria) (in 1971)

Gonorrhoea " 570 98 (17.2) (in 1977)

Trichomoniasis " " 1200 672 (56)

Fri)sner et al Gonorrhoea Stuttgart Culture 258 161 (62) 1975 (Rep.of

Germany) Hepatitis B " Anti-HBs 258 80 (31)

Hooper et al Gonorrhoea Philippines Cervical 511 90 (17.6) 1978 culture

Jaffe et a1 Gonorrhoea Fresno Not stated 451 89 (21. 7) 1979 County USA

Syphilis " 451 28 (6.3)

Jama et al. Chlamydia Mogadishu Urethra 58 19 (33) 1987 (Somalia) (ELISA)

Johnson et al Gonorrhoea Philippines Cervical 702 60 (8.5) 1969 culture

* Data are on female prostitutes, unless stated otherwise.

WHOJVDT/89.446 page 28

REFERENCE DISEASE PLACE METHOD NUMBER NUMBER STUDIED POSITIVE(%)

Khoo et al Gonorrhoea Singapore Cervical 200 16 (8) 19:77 culture

Syphilis " VDRL,FTA-ABS 200 92 (46)

Lahiri et al Gonorrhoea Agra Culture 50 21 (42) 1978 (India)

Syphilis " VORL 50 47 (94) Chancroid " Culture 50 17 (34) Genital warts " 50 3 (6)

Leeb et al. Gonorrhoea Taipei Cervical 515 43 (8.3) 1978 (Taiwan) culture

Meheus et al. Gonorrhoea But are Culture 86 44 (51. 2) 1974 (Rwanda)

Meheus et al Syphilis Butare VORL 43 12 (27.9) 19Y5 (Rwanda)

Nzilambi 1988 Gonorrhoea Kinshasa Cervical 668 187 (28) (Zaire) culture

Chlamydia " Cervical Ag 668 86 (13) detection ELisa

Syphilis " RPR,TPHA 668 106 (16)

Papaevangelou Hepatitis B Athens Anti-HBs 293 166 (56.7) et al. (Greece) 1974

Potter at et al Gonorrhoea Colorado Cervical 89 56 (63) 1979 Springs culture

(USA)

Reeves and Gonorrhoea Panama Cervical 956 100 (10) Quiroz culture 1987 39 12 (31)

(Street Walkers)

Syphilis " RPR 455 31 (7) 35 8 (23)

(Street Walkers)

Seliborska Gonorrhoea Warsaw Culture 92 29-48 (32-52) el al 1979 (Poland)

Stary et al. Chlamydia Vienna Cervical 270 55 (20.4) 1982 (Austria) culture (registered)

51 16 (31) (non-registered)

Teras et al. Trichomoniasis Germany Culture 41 15 (36.6) 1985

WHOjVDT/89.446 page 29

REFERENCE DISEASE PLACE METHOD NUMBER NUMBER STUDIED POSITIVE(%)

Traisupa ~ Gonorrhoea Bangkok Cervical 2146 956 44.5) 1988 Females (Thailand) culture

Early syphilis II VDRL,FTA-ABs 2146 216 (10.1)

Gonorrhoea Culture 2335 698 (29.9) Urethra (in 1987)

Males Rectum, Oropharynx

Early II VORL FTA-Abs 2335 77 (3.3) syphilis

WHOfVDT/89.446 page 30

REFERENCES

Alexander P. Prostitutes Prevent AIDS: A manual for health educators. California Prostitutes Education Project, San Francisco, 1988.

Anonymous. AIDS: Prevention, policies, and prostitutes. Lancet 1989; i 1111-1113.

Ansink-Schipper M C, Van Klingeren B, Huikeshoven M H, Woudstra R K, Dessens-Kroon M, Van Wijingaarden L J. Epidemiology of PPNG infections in Netherlands: analysis by auxanographic typing and plasmid identification. British Journal of Venereal Diseases 1984 ; 60 : 141-146.

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WHOfVDT/89.446 page 38

Members

LIST OF PARTICIPANTS

Dr O.P. Arya, Head of the University Department of Genito-Urinary Medicine, Royal Liverpool Hospital, Prescot Street, Liverpool L7 8XP, United Kingdom (Rapporteur)

Dr W. Darrow, Research Sociologist, AIDS Program, Centers for Disease Control, Atlanta, Georgia 30333, United States of America (Chairman)

Dr Antonio de Moya, PROCETS, Coronel Fernandez-Dominguez, Esquina 51, Ensanche la Fe, Santo Domingo, Dominican Republic

Dr H. Jama Ahmed, Department of Morphology and Pathology, Section of Bacteriology, Faculty of Medicine, Somali National University, Mogadishu, Somalia

Mrs E.N. Ngugi, University of Nairobi, Department of Community Health, Nairobi, Kenya (Vice-chairman)

Dr Nzila Nzilambi, Project SIDA Zaire, B.P. 8502, Kinshasa, Zaire

Dr J.K. Skripkin, Director, Central Research Institute of Skin and Venereal Diseases, Moscow, USSR*

Dr Titi Indijati Soewarso, Chief, Directorate of Direct Transmitted Disease Control, Ministry of Health, Jalan Percetakan Negara 29, P.O. Box 223 Jakarta, Indonesia

Dr T. Thirumoorthy, Consultant, Middle Road Hospital, 250 Middle Road, Singapore 0718

Dr A. Traisupa, Director, Venereal Disease Division, Ministry of Public Health, 189 Sathorntai Road, Bangkok, 10120, Thailand

Dr J. Visser, Sociologist, Mr de Graftstichting, Westermarket 4, 1016 DK Amsterdam, The Netherlands

Dr J.A.R. van den Hoek, Municipal Health Service, Nieuwe Achtergracht 100, Postbus 20244, 1000 HE, Amsterdam, The Netherlands

Dr H. Ward, Academic Department of Community Medicine, St. Mary's Hospital Medical School, Praed Street, London W2 lPG, United Kingdom

* Unable to attend

Observers

WHOfVDT/89.446 page 39

Dr W. Carswell, Regional Adviser, AIDSTECH Project, Family Health International, PO Box 13950, Research Triangle Park, NC 27709, USA

Dr G. Jessamine, Chief, Division of STD Control, Bureau of Communicable Diseases, Epidemiology, Laboratory Center for Disease Control, Ottawa, Ontario KlA OL2, Canada

Dr J. Van Dam, AIDS Task Force, Commission of European Communities, 67A Rue Joseph II, 1040 Brussels, Belgium

Dr M.A. Waugh, Secretary General, International Union Against the Venereal Diseases and the Treponematoses, The General Infirmary at Leeds, Great George Street, Leeds LSl 3EX, United Kingdom

WHO Secretariat

Dr B. Bytchenko, RA/EURO Drs C. Dasen, IEH/PSS Dr A. De Schryver, CDSfVDT Ms J. Ferguson, FHE/MCH Dr A. Meheus, CDS/VDT (Secretary) Dr 0. Meirik, HRP/HRD Mr W. Parra, CDS Dr P. Rowe, HRP/HRD Dr G. Torrigiani, CDS Dr R. Widdus, GPA/PCD Dr F. Zacarias, RA/PAHO